Position Description

SUMMARY

Provide direct and indirect nursing care to assigned participants primarily in the PACE clinic. Works under the direct indirect supervision of the Center Manager or designee but is independent in the application of advanced nursing knowledge and skills. Manages complex clinical situations for which he/she is responsible. Manages and understands the flow and needs of a clinic. Supervises both licensed and non-licensed personnel.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.

Assessment: Collects patient data and completes required forms with appropriate responses according to unit standards; identifies patient’s overt problems/needs and sets priorities; identifies problems requiring further referral and/or follow-up; interprets and records latest diagnostic results; performs phone triage assessments including but not limited to clinical triaging and reporting to medical providers and other clinical staff as indicated; performs advanced nursing assessments that are complex using critical thinking skills. Must anticipate the needs of the participants in an exam setting including supplies and interventions during procedures.
Planning Care: Develops a plan of care based on nursing processes and which incorporates the plans of other disciplines and continuing care needs; includes the participant/family in developing or revising the plan of care; makes referrals to multidisciplinary support services. Provides skilled nursing visits as ordered and as documented in the Plan of Care. Develops, implements, coordinates, and updates the participant specific care plan. Completes a clinical note in the health record for each skilled nursing visit, supervisory visit, and communication related to the coordination of care.

Implementing/Managing Care: Care provided conforms to accepted practice standards; provides correct treatments/procedures and other care as prescribed and according to patient care standards; demonstrates understanding of age-related characteristics and needs of patients served; explains nursing procedures in appropriate forms; provides discharge teaching; identifies emergency situations and independently initiates nursing actions; acts as coordinator of patient care with other health care personnel and evaluates patient care measures instituted; understands and demonstrates respect for patient rights and utilizes established mechanisms for management of ethical issues in patient care. Request necessary collaborative consultations as ordered by the physician.



Evaluation: Records patient care delivered as planned and any variation, with appropriate rationale; makes and records observations related to impending or associated problems. Completes all documentation in the medical record as required. Submits all required documentation, including, but not limited to, admissions, discharges, clinical notes, participant encounters, and nursing assessments

Leadership: Using nursing process, delegates nursing care to appropriate personnel; integrates cost effective measures into nursing practice; recognizes unit problems and takes responsibility for documenting same; demonstrates active participation in QI processes; complies with clinical expectations to meet staffing demands based on patient care needs; complies with policies addressing safe working conditions; monitors unsafe working conditions; recognizes inappropriate and/or ineffective patient care management, resolves issue/problem and completes written reports; fulfills call for unit as assigned and adjusts staffing for census (volume) and acuity. Evaluates and oversees the care given by LPNs and Certified Nursing Assistants as required by regulatory agencies. Ability to make independent nursing judgments and act on them for effective interventions.


• Knowledge of Infection control measures and the application of universal precautions.
• Knowledge of vaccines and the CDC guidelines and administration and documentation of vaccines. Knowledge of the care of vaccines in the clinic setting.
• Conducts initial and periodic assessments in the clinic and the home as needed
• Communicates participant changes to IDT
• Participates in the development of the IDT Plan of Care
• Participates in the coordination of a 24 hour care delivery
• Knowledge of caring for the aging person (geriatric nursing)
• Knowledge of the PACE organization and the interaction/functioning of ALF’s and SNF’s
• Performs routine medication reconciliation with participants, caregivers, and SNFs during the clinical visit.
• Assesses and maintains adequate inventory of clinic supplies and equipment
• Working understanding and knowledge of Advance Directives.
• Knowledge of palliative care

• Fulfills shared after hour nursing on call responsibilities
• Participates in educational seminar/programs per approval.
• Maintains the established community practice standards for home health care.
• Performs related other duties as assigned by management.
• Maintain clinic operations in accordance with local, state, federal guidelines.

SUPERVISORY RESPONSIBILITIES
Responsible to oversee and evaluate the client care provided by LPN's and Certified Nursing Assistants, as per regulation requirements, and provides performance input to the member’s supervisors. Responsibilities include addressing complaints and resolving problems.

WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee regularly works in client's home. The employee is frequently exposed to traffic and frequently works with confused, potentially aggressive and/or upset participants, and may experience interruptions. The employee occasionally works in office environment. The noise level in the work environment is usually moderate.
SAFE WORK EXPECTATIONS

The safety of employees, residents and visitors is of paramount importance to Neighborly Care Network PACE. Our work place safety program will be incorporated as the standard of practice for this organization. Compliance with these safe work expectations will be required of all employees as a condition of employment. Our organization focus will hold all employees accountable for safety performance equal with quality and production expectations.

Employees will be expected to:

1. Follow correct policy and procedures for department and facility Fire/Disaster/Missing Person Plan. Know the location of fire alarms and extinguishers.
2. Follow correct policy and procedure for hand washing.
3. Follow guidelines for proper method of lifting.
4. All doorways, hallways and areas are to be kept clear.
5. Follow guidelines for department environment and safety measures.
6. Follow guidelines for safe handling, inspection, maintenance and storage of equipment. Report any malfunction of equipment.
7. Follow guidelines for safe handling and storage of chemicals and supplies.
8. Follow correct policy and procedure for reporting of incidents: staff, residents, etc.


TRAINING REQUIREMENTS

1. Annual HIPAA Training
2. Annual Compliance and Competency Training
3. Neighborly Care Network PACE Policies
4. Computer Training

Position Requirements

QUALIFICATIONS, SKILLS AND ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Successfully complete a Competency Assessment upon hire and receive annual competency assessments.
2. Knowledge of Neighborly Care Network’s PACE Policies & Procedures.
3. Knowledge of Human Development, including the process of aging.
4. Record keeping and clerical office procedures.
5. Effective oral and written communications.
6. Work efficiently under pressure with deadlines.

7. Work effectively with community/statewide agencies.
8. Maintain department, agency and client confidentiality.
9. Knowledge of Home Health

EDUCATION and/or EXPERIENCE
Graduation from an accredited school of Nursing; Bachelor's degree in nursing is preferred. Five years of nursing experience in Home Health, Palliative Care, Acute Care, or Ambulatory clinic preferred or any combination of training, education and experience which provides the required knowledge, skills and abilities.

CERTIFICATES, LICENSES, REGISTRATIONS
• Valid Fla. Driver's License and car insurance
• Abuse and Criminal Background Check
• Licensed RN
• Statement of Good Health and TB Test

PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to stand; walk; sit; use hands and fingers; reach with hands and arms; climb stairs; and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 25 pounds. Must be able to operate a personal motor vehicle. Must be able to make home visits to all parts of Pinellas County. Must occasionally transfer clients up to 150lbs from bed to chair and safely reposition clients in bed for the purpose of assessing medical concerns.